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A 18-year-old male presented with Fever, headache and body ache

Dr. Shahnaz Parveen

MD Resident (Phase-A)

Class Room Hematology

10.00am 16.5.2022

Department of Hematology

BSMMU

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Particulars of the patient

  • Name: Rimon
  • Age: 18 years
  • Sex: Male
  • Religion: Islam
  • Occupation: Student
  • Address: Kaliakoir, Savar
  • Date of Admission: 28th April, 2022
  • Date of Examination: 12 May, 2022

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Presenting Complaints

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  • Fever for 2months.

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  • Multiple purpuric spot in body for 1month

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  • Headache and Body ache for 2months.

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History of present illness

According to patient statement he was reasonably well 2 months back then he developed fever which is

  • High grade, intermittent .
  • Highest recorded temperature was 103 °F.
  • Relieved by taking paracetamol .
  • Fever is not associated with chills and rigor , there is no diurnal variation and night sweat.

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History of present illness (cont’d..)

The patient noticed multiple purpuric spot of varying size all over his body for one month which are,

  • Painless, non itchy ,non palpable .
  • Which were initially bright red then dark and disappear following transfusion.
  • He also gave history of nasal and per rectal bleeding during defecation for same duration.

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He also complaints of headache for 1month which is

  • Generalized , dull aching.
  • Severe
  • Aggravated by standing, walking and cough.
  • Subsided by taking analgesics.
  • Associated with blurring of vision.
  • Not associated with vomiting, photophobia or any aura

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He also complaints of generalized, severe bodyache. .

There is no history of jaundice, contact with TB patient, travelling to malaria endemic zone, loss of consiousness , convulsion, joint pain or alopecia weight loss.

After admission, the patient developed drooping of angle of mouth towards left side.

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History of Past illness

There was no history of major surgery or trauma.

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Treatment History

For his fever he visited local physician and undergone several investigation and was given some medications, but he could not mention the name of drug.

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�Family History�

Parents are alive. He has 3 siblings. One of his brother died of electric shock.

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Personal History

No history of betel nut chewing, smoking or taking alcohol.

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Immunization history

Immunized as per EPI schedule, he took 2 dose of covid vaccine.

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Transfusion history

He received 12 units of PRBC over last two months and 6unit platelet.

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Physical examination

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General Examination

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  • Appearance- Ill looking.
  • Body build- Normal
  • Nutritional status- Average
  • Cooperation- Cooperative
  • Decubitus- On choice
  • Anemia- Moderate
  • Jaundice- Absent
  • Cyanosis- Absent
  • Clubbing- Absent

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General Examination(cont’d…)

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  • Koilonychia- Absent
  • Leuconychia- Absent
  • Pulse- 82 b/p/m
  • BP- 100/70 mm hg
  • Temperature- 98℉
  • Respiratory rate- 20/min

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General Examination(cont’d…)

  • Edema- Absent
  • Dehydration- Absent
  • Pigmentation-Absent
  • Lymph nodes- No palpable lymphadenopathy
  • Thyroid gland- Not enlarged
  • Neck Veins- Not engorged
  • Bony tenderness – Present

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Systemic Examination

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Nervous system examination

  • Higher psychic function- Intact
  • Speech – Slurred
  • Cranial nerve- There is left sided LMN type facial palsy
  • Motor and sensory system of both upper and lower limb reveals normal.
  • Neck rigidity- Absent
  • Kerning sign- Absent
  • Fundoscopy - Not done
  • Rest of the cranial nerves are intact

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7th cranial nerve examination�

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7th cranial nerve examination continue

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Abdomen

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Inspection:

  • Umbilicus is centrally placed and inverted.
  • Flanks are not full.
  • No visible peristalsis, no other pulsation.
  • No dilated vein, scar mark or sinus.
  • Hernial orifices are intact.

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Superficial Palpation �

  • Local temperature: Normal
  • No tenderness
  • No rigidity

Deep palpation

  • Liver- Not palpable
  • Spleen- Not enlarged
  • Kidneys- are not ballotable

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  • Both testes are normal in position and healthy.

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Abdomen(cont’d)…

Percussion:

  • Percussion note is tympanic.
  • Ascites absent (Evident by negative shifting dullness).

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Auscultation

  • Bowel sound: Present
  • No bruit.

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  • Cardiovascular system : Normal
  • Respiratory system : Normal
  • Musculoskeletal system: Normal
  • Other systemic examinations reveal NAD

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Salient features

Rimon 18year old student normotensive non-diabetics hailing from savar , kaliakoir admitted here with the complaints of fever, purpuric spot, headache and body ache.

Fever is high grade intermittent, highest recorded temperature is 103ᵒ F, relieves by taking paracetamol and not associated with chills and rigors or diurnal variation.

Then patient noticed multiple purpuric spot of varying size all over his body for one month which are, painless, non itchy ,non palpable, which were initially bright red then dark and disappear following transfusion

He also complaints single episode of epistaxis and melena for 2months.

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He has headache for 2months, which is generalized dull aching, aggravated by standing, walking and cough, subsided by taking analgesics, associated with blurring of vision, not associated with vomiting, unconsciousness ,convulsion or aura.

He has no history of pruritus, night sweat ,cough, hemoptysis , oral ulcer, arthralgia and alopecia or contacted with TB patient.

He received 12 unit of PRBC and 6unit of platelets in last 2months.

On general examination patient was ill looking,moderately aneamic,bony tenderness present. Patient is non icteric on cyanotic, koilonychia ,leukonychia , clubbing absent. His BP 110/70mmhg, pulse 82 b/min, RR 20br/min.

Nervous system examination reveals left sided facial asymetry, failure of wrinkling of forehead of left side, the left eye cannot be closed, failure to whistle and smile, while showing the teeth lips are drawn to right side.

Other systemic examination reveals no other abnormality.

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What will be the diagnosis ?

?????

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Differential diagnosis

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  1. Leukemia with LMN type facial palsy
  2. Lymphoma with LMN type facial palsy

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CBC on 21th April

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Peripheral blood film on 21april

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CBC on 24th April

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Test 16th march 2022

Results

Bilirubin(T)

0.4mg/dl

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Plasma glucose (random)

9.0mmol/l

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Serum Electrolytes

Sodium

Potassium

Chloride

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133mmol/l

4.3mmol/l

96mmol/l

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ALT

184.11U/L

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AST

204U/L

CRP

25.4 mg/l

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Albumin

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43gm/l

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Test 29th April 2022

Result

Magnesium

1.6mg/dl

Calcium

9.3mg/dl

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Uric Acid

7.8mg/dl

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Phosphate

4.4mg/dl

Serum creatinine

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0.97mg/dl

Gamma gt

350u/l

LDH

>4500U/L

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USG of whole abdomen

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X-ray PNS OM view on 18th april

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Echocardiography on 5th april

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Ct-scan of brain

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PT and APTT on 18th april

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Bone marrow examination on 24th april 2022

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Results of flow cytometry

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Confirmatory Diagnosis�

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Acute lymphoblastic leukemia (B-ALL) BCR-ABL negative with left sided LMN type facial nerve palsy

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